Smoking Cessation Program

We have been providing smoking cessation counseling for one year now and we are evaluating our program. We are interested in how successful the smoking cessation program has been for patients in helping them quit smoking. The answers will be pooled with no identifying information. Thank you for your time.

Sincerely, Kathryn Flanigan, NP for the Centre for Family Medicine

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1.Who did you see for counseling?

Kathryn (Nurse Practitioner)

Maria (Nurse Practitioner)

Sabrina (Nurse)

Michelle (Nurse)

Dawn (Physician Assistant)

Angela (Respiratory Therapist)

Unsure

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2.Did you have a follow up appointment?

Yes

No

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3.If you answered yes... with whom did you have a follow up appointment?

Kathryn (Nurse Practitioner)

Maria (Nurse Practitioner)

Sabrina (Nurse)

Michelle (Nurse)

Dawn (Physician Assistant)

Angela (Respiratory Therapist)

Physician

Unsure

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4.If you answered no... why not?

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5.Did you use any smoking cessation aids? Check all that apply.

Champix

Zyban

NRT Patch

NRT Gum/Lozenge

NRT Mist

NRT Inhaler

Alan Carr Book

Other (please specify)

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6.Did you quit smoking? If you answered yes... for how long?

Less than 7 days

8 days to 30 days

1-6 months

More than 6 months

Still smoke free

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7.If not, did you cut down smoking? How much?

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8.Did anyone in your family quit smoking with you?

Yes

No

No but s/he cut down

No, does not smoke

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9.If you did not quit smoking, do you want to make another appointment to try again? If not, why?

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10.What did you find most helpful in the counseling sessions? What could we do to improve the program? Do you have any further comments?